1)Contact Info: Name, Email and Phone ______

Date ______

1)Contact info: Name, email and phone ______

2)What type of opportunity are you interested in (its ok if you don’t know)

3)How did you find out about us? ______

4)Any specific populations of clients/patients you are interested in? (Pediatrics, geriatric, youth, Psychology, men’s health, women’s health, etc) ______

5)What is your training background roughly

6)When are you looking to begin time/volunteer or rotate with us (ie May 20XX, July 20XX) ______

7)How many hours per week and how long can you volunteer? ( i.e. 10 hours per week for five months from July through November) ______

8)What institution are you currently affiliated with or any institutions or organizations you used to work with. ______

9)Do you have a CV you can share (its OK if you don’t) ______

10)Are you interested in research projects? ______

Approved - ______(VP or higher) Date: ______

______

Last NameFirst Name Middle InitialGender

______

AddressCityState Zip

______

Email AddressPrimary PhoneCell Phone

May we mention Howard Brown when calling?□Yes□No

Best time to call: □Day □Evening

Employer (if applicable):______

Job Title: ______

Highest Level of Education:

11/28/2018

□Some High School

□ High School Diploma

□ Some College

□Associate’s Degree

□ Bachelor’s Degree

□ Graduate Work

□ Master’s Degree

□ Doctoral Work

□ Doctorate

11/28/2018

College major (if applicable): ______

Are you fluent in a second language? □Yes□No

If so, please list ______

Please indicate the times you are available to volunteer. If you are not able to work on a given day, please specify in the box provided.

11/28/2018

Monday:______□None

Tuesday______□None

Wednesday:______□None

Thursday:______□None

Friday: ______□None

Saturday: ______□None

Sunday: ______□None

11/28/2018

Application continued.

Areas of interest (please check all that apply):

11/28/2018

□Administrative Support

□BroadwayYouthCenter mentor

□BYC HIV/STI Test Counselor

□ BYC Donations Pick-Up & Fundraising

□BYC Programming & Training

□Drop-In Worker

□ Brown Elephant Resale Stores

□Front Desk Receptionist

□ Outreach

□ Development

□ Special events

□ Other______

11/28/2018

Please describe any previous volunteer experience: ______

______

What skills do you possess and/or hope to gain from your volunteer experience? ______

______

How long would you like to volunteer for Howard Brown?

□ One-Time□ Short-Term□ Ongoing□ Unsure

Why are you interested in becoming a Howard Brown volunteer? ______

______

Please provide the names and contact information of two unrelated personal references.

______

First Reference NameRelationship

______

AddressCityStateZip

______

Phone numberEmail Address

______

Second Reference NameRelationship

______

AddressCityStateZip

______

Phone numberEmail Address

Thank you for your support!

If you have any questions, please feel free to contact us at .

All information contained in this application is confidential.

11/28/2018

Volunteer Application

Pledge of Confidentiality

It is the goal of HowardBrownHealthCenter (Howard Brown) to provide our clients (anyone seeking care or services with or through Howard Brown) with professional, competent and quality care and education in a respectful, affirming atmosphere. As an employee, consultant, auditor, or volunteer of Howard Brown, you have a responsibility to maintain a sense of concern and professionalism while performing your duties. In the execution of this duty, you must be sensitive to the comfort, sensitivities, and confidentiality of the client.

The comfort and confidentiality of our clients is of primary concern to Howard Brown. The professionalism of our staff is necessary to maintain the comfort and trust we have built through the years. Courts and health care professionals maintain that upholding patient confidentiality is an absolute necessity. Federal Courts guarantee absolute privacy regarding all STD medical records. Furthermore, sexual health histories may not be subpoenaed by any court. Breaches of confidentiality regarding the aforementioned data may be punished by dismissal. As an employee, consultant, auditor, or volunteer of Howard Brown, it is imperative that you follow all Federal, state and local confidentiality laws.

In addition to the legal confidentiality laws, as an employee, consultant, auditor, or volunteer of Howard Brown, you must also abide by the following:

In the context of our duties, some of us advise within the clinical setting appropriate behavior as it pertains to physical and/or mental wellness. In the context of this document, clinical setting includes all areas and/or physical space in which you perform your assigned duties.
We do not, and can not, be “moral custodians,” nor do we have policing rights.
Do not discuss clients or client data with unauthorized persons.
Discuss clients or client data only to conduct legitimate business, and such discussions should take place only in a manner(s) and location(s), which affords absolute privacy.
Do not discuss clients or patients outside of Howard Brown for any reason.
Make no reference to a client visit to Howard Brown should you meet a client elsewhere.
Preserve the confidentiality of friends who are Howard Brown clients as you would any Howard Brown client.
Never acknowledge the presence or absence of clients to any caller.
Respect for clients is mandatory as a representative of Howard Brown.
Client confidentiality is respected and maintained by all staff and other members of the Howard Brown workforce after concluding their working relationship with Howard Brown.

BREACH(ES) OF CONFIDENTIALITY WILL NOT BE TOLERATED AND IS GROUND FOR IMMEDIATE DISMISSAL.

We guarantee our clients absolute confidentiality of their records. Any client requesting a copy of their records must follow the Howard Brown Policy of Chart Access. No person shall be permitted to view client medical, mental health, or case management records, unless written documentation of permission by the client involved is provided.

Your signature below confirms that you have read, understand and accept to follow HowardBrownHealthCenter’s Pledge of Confidentiality.

Signature: ______

Print Name: ______Date: ______

Emergency Contact Information

In the event of a personal emergency occurring while at work, I authorize HowardBrownHealthCenter to directly contact the following:

______
NameRelationship

______

AddressCity StateZip

______

Primary Phone Number

In case of emergency, I also (authorize/do no authorize) HowardBrownHealthCenter to release the above listed contact information to hospitals, doctors, medical units, or law enforcement officers/agencies:

Authorize

Do Not Authorize

Signature: ______

Print Name: ______

Date: ______

Employee/Volunteer No Harassment Policy

HowardBrownHealthCenter will not tolerate sexual harassment of or by its employees/volunteers. This means that the following behaviors are grounds for disciplinary action, including termination:

unwelcome sexual advances;
requests for sexual acts or favors;
abusing the dignity of an employee/volunteer through insulting or degrading sexual remarks or conduct;
threats, demands, or suggestions that an employee’s/volunteer’s work status is contingent upon her or his toleration of or acquiescence to sexual advances; or
retaliation against employees/volunteers for complaining about such behaviors.

Nor will HowardBrownHealthCenter tolerate harassment on the basis of race, gender, age, religion, disability, sexual orientation, gender expression, veteran or marital status, national origin, or ancestry. The following behaviors are grounds for disciplinary action, including termination:

Epithets, slurs, negative stereotyping, or threatening, intimidating or hostile acts that relate to such status; or
written or graphic material that denigrates or shows hostility or aversion to an individual because of such status and that is placed on walls, bulletin boards, or anywhere else in the workplace or is circuited in the workplace.

If you encounter such behavior from anyone, including supervisors, fellow employees, volunteers, contract staff or clients, you must bring the problem to the attention of the Volunteer Coordinator. This is the proper and required course. Instigating or spreading rumors of alleged harassment among fellow employees/volunteers is not the proper course and may result in disciplinary action.

All complaints will be promptly handled and privacy safeguards will be applied in handling harassment complaints.

I have read and understand the HowardBrownHealthCenter policy on No Harassment.

Signature: ______

Print Name: ______

Date: ______

Volunteer Drug and Alcohol Policy

I.General Policy. HowardBrownHealthCenter (Howard Brown) is committed to policies that promote safety in the workplace, volunteer health and well-being, and patient/client confidence. Drugs and alcohol abuse can adversely affect job performance and morale, jeopardize volunteer and patient/client safety, undermine patient/client confidence and reflect negatively on the reputation of HBHC in the community. Howard Brown’s goal, therefore, and the purpose of this policy, is to establish and maintain a healthy and efficient work force free from the effects of drug and alcohol abuse. Consistent with this goal and commitment, and in accordance with the requirements of the Drug-Free Workplace Act of 1989, Howard Brown has developed this Drug and Alcohol Policy (the "Policy").

II.Use, Possession, Sale, Distribution, or Being Under the Influence. The use, possession, sale or distribution of, or being under the influence of, illegal drugs or alcohol while on Howard Brown property or on Howard Brown business will be cause for discipline, up to and including immediate discharge. Off-premises/off-work use, possession, sale or distribution of controlled drugs reflecting negatively on Howard Brown also will be cause for discipline up to and including immediate discharge. The use of a prescribed medication by a person for a purpose other than for which it was prescribed or by persons to whom it was not prescribed constitutes illegal drug use and is a violation of this policy. Illegal substances discovered on Howard Brown property will be turned over immediately to the appropriate law enforcement agencies.

III.Alcohol consumption in business or social contexts. Howard Brown on occasion hosts events where alcoholic beverages may be legally consumed. There may be other instances when volunteers are with clients and/or donors when the social circumstances may justify the consumption of alcoholic beverages. In such circumstances, volunteers must exercise their best judgment with due regard for the effect their consumption of alcohol may have on their behavior, safety, job performance, and the reputation of Howard Brown. Volunteers whose consumption of alcoholic beverages in these circumstances adversely affects their behavior or job performance may be subject to disciplinary action up to and including immediate discharge, even for the first offense.

IV.Suspicion of Drug Use. A volunteer suspected of being under the influence of any illegal or controlled drug by a supervisor’s observation, including but not limited to marijuana, heroin, cocaine, morphine, phencyclidine (PCP), amphetamines, barbiturates, or hallucinogens (or metabolites of any such drugs), shall be subject to discipline, up to and including immediate discharge.

V.Alcohol in the System. A volunteer suspected to be under the influence of alcohol by a supervisor's observation will be subject to discipline, up to and including immediate discharge.

VI.Searches. Pursuant to this Policy, Howard Brown reserves the right to carry out reasonable searches of its facilities and volunteers and their property, including but not limited to desks, lockers, clothing, lunch boxes, and private vehicles if parked on Howard Brown property. A volunteer who refuses to submit immediately to such a search shall be subject to immediate discharge. Searches will always be conducted by at least two persons, one being a department head or senior executive who serve as witnesses in the presence of the suspected volunteer.

VII.Drug Paraphernalia. Volunteers are prohibited from bringing illegal drug paraphernalia onto Howard Brown property at any time. A volunteer who possesses or distributes such illegal paraphernalia while on Howard Brown property shall be subject to disciplinary action up to and including immediate discharge.

Over-the-Counter or Prescribed Medications. Volunteers who take over-the-counter or prescribed medication are responsible for being aware of any effect the medication may have on the performance of their duties.

IX.Reporting Violations. Each volunteer is responsible for immediately reporting unsafe working conditions or hazardous activities that may jeopardize his or her safety or the safety of fellow employees or clients. This includes the responsibility to immediately report any violation by other employees/volunteers of this Policy. A volunteer who fails to report such a violation is subject to disciplinary action, up to and including immediate discharge.

X."Howard Brown Property" Defined. For purposes of this Policy, the term "Howard Brown property" includes all land, buildings, structures, parking lots, and means of transportation owned by or leased to the Company.

XI.Progressive Discipline Not Applicable. Any other disciplinary methods used by the HBHC do not apply to violations of this Policy. Discipline for violations of this Policy shall be governed solely by the Policy itself.

Acknowledgment of Drug and Alcohol Policy

As a condition of utilization, Howard Brown requires that I acknowledge receipt of the Howard Brown Health Center Drug and Alcohol Policy and agree to abide by the terms and conditions of the policy. I further agree, in compliance with state and federal drug-free workplace regulations, that I will notify Howard Brown of any criminal drug statute conviction for a violation occurring in the workplace no later than 24 hours after the conviction.

Signature: ______

Print Name: ______

Date: ______

Volunteer Application

Background Check

In connection with your application and anytime during your term of service you authorize Midwest Backgrounds, Inc (“MBI”) to obtain and furnish consumer reports from various credit reporting agencies and other reports from various agencies and organizations regarding your personal, residential, employment, criminal, driving, lawsuit, workers’ compensation, education, character and reputation records and history to Howard Brown periodically or on an ongoing basis during your term of service.

MBI DOES NOT INDEPENDENTLY ANALYZE, EVALUATE OR SUMMARIZE THE CONTENTS OF ANY SUCH REPORTS.

The amended Fair Credit Reporting Act (1997) requires that we inform you that a background check may be conducted as part of our employment screening process and/or during employment. The main objective of the background check is to verify information you provided on your application/resume or during the interview process. In the event that any report is utilized in making an adverse decision regarding your potential employment, MBI will provide you with an address to obtain a copy of the information or report and a description in writing of your rights under the law prior to making such an adverse employment decision. We will provide you with the disclosure within five (5) business days of the date on which we receive your written request.

I hereby authorize and request all credit reporting agencies, circuit courts and their officers, officials and employees, state agencies and their officials and employees, local and state law enforcement agencies, federal law enforcement agencies, International law enforcement agencies, department of motor vehicle facilities, past/present employers and educational institutions, labor and worker’s compensation departments, and any other agency or person having information relevant to my background for employment purposes, to release any and all information upon MBI’s request. I further release, hold harmless and agree to indemnify any of the foregoing from any and all liability, injury, damages, claims, demands, causes of action, suits, judgments and executions, whether sounding in tort, contract, equity or law, which I and my heirs, personal representatives, assigns, executors and administrators now have, or in the future may have, against any of the foregoing for providing the requested reports to MBI.

PLEASE TYPE OR PRINT LEGIBLY

Applicant Name:

______

LastFirstMiddle

Other names known by (Including Maiden)______

______

StreetCityStateZipCounty

Date of Birth: _____/______/______SS#: ______

Background Check Continued

Male / Female (Circle One) Race ______

Driver’s License # ______State ______

Home Addresses for the Past 7 Years:

City State Zip County Dates: Mo/Year

______

Previous Felony/Misdemeanor Criminal Convictions? _____Yes _____No

Charge/Conviction County State Dates Mo/Year

______

By my signature below, I hereby authorize Midwest Backgrounds, Inc. to obtain my personal history. I hereby state that I have read this document in detail and clearly understand the terms and rights that I have granted to M.B.I. for the collection and release of the aforementioned information.

Applicant Signature ______

Date ______

Please give Summary of Rights to applicant